Inquiry hears of “glaring omission” in child death review

A former medical director who ordered a review into the death of a 17-month-old girl has said it was a “glaring omission” that her parents were not interviewed as part of the investigation into the toddler’s death.

The Hyponatraemia Inquiry heard today that the parents of Lucy Crawford did not become aware of the review until they initiated their own complaints procedure about their daughter’s case, two months after the review findings were published.

Speaking at the Hyponatraemia Inquiry Dr James Kelly conceded that there was no “rule book” at the time on how a review should have been carried out.

Lucy was pronounced dead at the Royal Belfast Hospital for Sick Children in April 2000 after being transferred from the Erne Hospital.

For more background information on the issues being examined by the Hyponatraemia Inquiry please click here.

Dr Kelly was medical director of the Sperrin Lakeland Trust from 1999-2003. Along with the chief executive of the trust, Hugh Mills, he agreed that a review should be carried out into Lucy’s case.

Giving evidence to the inquiry, Dr Kelly said that because of his work load at the time, he was supposed to devote half of his time to his role as medical director but “in reality” this only translated into one fifth of his time.

Questioning Dr Kelly on this point, junior counsel for the inquiry Mr Martin Wolfe asked him if this had an impact on his ability to fulfil his role in relation to the review into Lucy Crawford’s death. Dr Kelly said:

A: It’s for others to judge how effective the investigations or reviews were, but it must have had an impact on every area of my work, including the work relevant to the inquiry.

Q: Are you saying looking back on it you wish you’d have been able to do things somewhat better, but at least some of this has to be understood in the context of the restrictions in which you were under.

A: I think that’s fair.

Dr Kelly agreed with junior counsel’s point that in 2000 there was no “rule book” to be followed in terms of how a typical review would be undertaken at the time.

Dr Trevor Anderson, clinical director of women and children’s service at the Erne Hospital, and Mr Eugene Fee, director of acute hospital services at the Sperrin Lakeland Trust, were tasked with carrying out the review into Lucy’s death.

Mr Wolfe outlined that as part of the review written statements were taken from nursing and clinical staff but they were not interviewed in person for the review. Dr Kelly agreed that he would have expected this to have been carried out.

Mr Wolfe also questioned Dr Kelly on why Lucy Crawford’s parents were not interviewed as part of the review following her death.

Q: Another area of work that might have been explored by the review team, which wasn’t, was a contribution from the family. Did you know that they weren’t going to approach the family for evidence?

A: I didn’t know that they had taken a direct decision to do it or not to do it. Am I surprised? Not really. It wasn’t the standard of the time; it wasn’t what was done routinely. It’s completely different now. It’s been completely different for years now. But at the time it wasn’t unusual to proceed with the review, on some kind of, I suppose humanitarian front we don’t want to upset the family so close to the event. But obviously one looks back and goes ‘it’s a glaring omission’.

Q: Well it’s clearly a glaring omission doctor, and we don’t necessarily need the benefit of hindsight to say so because, as you would be aware from the report, Dr Quinn was bemoaning the lack of detail around the incident or the event that happened at 3am in terms of the nature of the event. And one of the, if you like, pieces of evidence that could have filled that gap would have been information from the family.

A: I think it would have helped.

The chairman also questioned Dr Kelly on this point:

Q: It’s not hard to approach the family and say, ‘look we’re doing a review. It would be helpful to have your input but we entirely understand if you don’t want to engage.’

A: And I think that’s entirely the approach that would have been taken in the last five or ten years.

The inquiry heard that the findings of the review were published in July, but that Lucy’s parents did not become aware of the existence of the review into Lucy’s death until they began their own complaints procedures in September.

Dr Kelly said he was “horrified” when he found out that the family were not aware of the review and that it was his understanding that Dr O’Donohoe, who initially treated Lucy at the Erne Hospital, had already informed the family that an investigation was planned.

Dr Kelly said he could not explain why the parents were not told about the review.

Later in this afternoon the chairman discussed the fallout of the review’s shortcomings with Dr Kelly.

The chairman said:

Q:The basic problem here is doctor as you now know better than I do, this review did not turn up went wrong. I understand how governance was developing in 2000, but what you have is a 17-month-old girl who came into hospital not very ill and within a few hours she was effectively dead.”

The chairman said that as a result of this, lessons that may have been learnt before the death of Raychel Ferguson a number of months later were not. Dr Kelly said he understood the implications of that.

The chairman also asked Dr Kelly if following Lucy’s death it was his understanding that this was clearly a case for the coroner:

A: Yes I think it would be my understanding and the understanding of all the other clinicians as well.

Q: You mean in the Erne?

A: I think so.

As previously reported by The Detail, Lucy’s death was not referred to the coroner and a hospital post mortem examination was directed.

The inquiry has already heard extensive evidence about conversations and decisions made in the aftermath of Lucy’s death and ultimately why this did not prompt a coroner’s post mortem.